RSS-Feed abonnieren
DOI: 10.1055/s-0042-1745861
Portal Hypertension and Current Endoscopic Management
![](https://www.thieme-connect.de/media/10.1055-s-00032260/202202/lookinside/thumbnails/10-1055-s-0042-1745861_2100045-1.jpg)
Abstract
Portal hypertension is a difficult to treat sequelae of end stage of liver disease, and is associated with a variety of complications. Notably, it can lead to significant gastrointestinal bleeding, which carries a high risk of mortality. Sources of portal hypertensive bleeding include esophageal and gastric varices, portal hypertensive gastropathy and ectopic varices. Fortunately, endoscopic techniques are effective in both prevention and management of acute bleeding, and their application and expansion has led to improved outcomes. Endoscopy plays a pivotal role as it allows for direct visualization and diagnosis as well as immediate intervention. There are several endoscopic techniques available for the treatment of esophageal varices including band ligation, glue therapy and sclerotherapy. There are, however, gray areas within the management of portal hypertensive bleeding such as the management of portal hypertensive gastropathy and gastric variceal bleeding, both of which can be more challenging to treat endoscopically. Thus, there is growing interest regarding how novel advanced therapeutic techniques can address these areas with a focus on endoscopic ultrasound guided therapies. This article will review both traditional and novel endoscopic techniques used in the management and prevention of portal hypertensive associated bleeding.
Keywords
hypertension - portal/complications - hypertension - portal/therapy - esophageal and gastric varices - endoscopy - liver cirrhosis - end stage liver diseaseFinancial Interests
The authors indicated no actual or potential financial interests in this article.
* These authors contributed equally to first authorship.
Publikationsverlauf
Eingereicht: 30. September 2021
Angenommen: 24. Januar 2022
Artikel online veröffentlicht:
23. Mai 2022
© 2022. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA
-
References
- 1 Paik JM, Golabi P, Younossi Y, Mishra A, Younossi ZM. Changes in the Global Burden of Chronic Liver Diseases From 2012 to 2017: The Growing Impact of NAFLD. Hepatology 2020; 72 (05) 1605-1616
- 2 de Franchis R, Baveno VI. Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63 (03) 743-752
- 3 García-Pagán JC, Reverter E, Abraldes JG, Bosch J. Acute variceal bleeding. Semin Respir Crit Care Med 2012; 33 (01) 46-54
- 4 Bosch J, García-Pagán JC. Prevention of variceal rebleeding. Lancet 2003; 361 (9361): 952-954
- 5 Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases. [published correction appears in Hepatology. 2017 Jul;66(1):304] Hepatology 2017; 65 (01) 310-335
- 6 Sanyal AJ, Bosch J, Blei A, Arroyo V. Portal hypertension and its complications. Gastroenterology 2008; 134 (06) 1715-1728
- 7 Groszmann RJ, Garcia-Tsao G, Bosch J. et al; Portal Hypertension Collaborative Group. Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med 2005; 353 (21) 2254-2261
- 8 Habib A, Sanyal AJ. Acute variceal hemorrhage. Gastrointest Endosc Clin N Am 2007; 17 (02) 223-252 , v
- 9 Moitinho E, Escorsell A, Bandi JC. et al. Prognostic value of early measurements of portal pressure in acute variceal bleeding. Gastroenterology 1999; 117 (03) 626-631
- 10 Sarin SK, Wadhawan M, Agarwal SR, Tyagi P, Sharma BC. Endoscopic variceal ligation plus propranolol versus endoscopic variceal ligation alone in primary prophylaxis of variceal bleeding. Am J Gastroenterol 2005; 100 (04) 797-804
- 11 Puente A, Hernández-Gea V, Graupera I. et al. Drugs plus ligation to prevent rebleeding in cirrhosis: an updated systematic review. Liver Int 2014; 34 (06) 823-833
- 12 Cipolletta L, Bianco MA, Rotondano G, Marmo R, Meucci C, Piscopo R. Argon plasma coagulation prevents variceal recurrence after band ligation of esophageal varices: preliminary results of a prospective randomized trial. Gastrointest Endosc 2002; 56 (04) 467-471
- 13 Nakamura S, Mitsunaga A, Murata Y, Suzuki S, Hayashi N. Endoscopic induction of mucosal fibrosis by argon plasma coagulation (APC) for esophageal varices: A prospective randomized trial of ligation plus APC vs. ligation alone. Endoscopy 2001; 33 (03) 210-215
- 14 Li X, Jiang T, Gao J. Endoscopic variceal ligation combined with argon plasma coagulation versus ligation alone for the secondary prophylaxis of variceal bleeding: a systematic review and meta-analysis. Eur J Gastroenterol Hepatol 2017; 29 (06) 621-628
- 15 Villanueva C, Colomo A, Bosch A. et al. Transfusion strategies for acute upper gastrointestinal bleeding. [published correction appears in N Engl J Med. 2013 Jun 13;368(24):2341] N Engl J Med 2013; 368 (01) 11-21
- 16 Bernard B, Grangé JD, Khac EN, Amiot X, Opolon P, Poynard T. Antibiotic prophylaxis for the prevention of bacterial infections in cirrhotic patients with gastrointestinal bleeding: a meta-analysis. Hepatology 1999; 29 (06) 1655-1661
- 17 Wells M, Chande N, Adams P. et al. Meta-analysis: vasoactive medications for the management of acute variceal bleeds. Aliment Pharmacol Ther 2012; 35 (11) 1267-1278
- 18 Bosch J, Thabut D, Bendtsen F. et al; European Study Group on rFVIIa in UGI Haemorrhage. Recombinant factor VIIa for upper gastrointestinal bleeding in patients with cirrhosis: a randomized, double-blind trial. Gastroenterology 2004; 127 (04) 1123-1130
- 19 Van Stiegmann G, Cambre T, Sun JH. A new endoscopic elastic band ligating device. Gastrointest Endosc 1986; 32 (03) 230-233 DOI: 10.1016/s0016-5107(86)71815-4.
- 20 Nett A, Binmoeller KF. Endoscopic Management of Portal Hypertension-related Bleeding. Gastrointest Endosc Clin N Am 2019; 29 (02) 321-337
- 21 Dai C, Liu WX, Jiang M, Sun MJ. Endoscopic variceal ligation compared with endoscopic injection sclerotherapy for treatment of esophageal variceal hemorrhage: a meta-analysis. World J Gastroenterol 2015; 21 (08) 2534-2541
- 22 Krige JE, Bornman PC, Goldberg PA, Terblanche J. Variceal rebleeding and recurrence after endoscopic injection sclerotherapy: a prospective evaluation in 204 patients. Arch Surg 2000; 135 (11) 1315-1322
- 23 Scheurlen C, Roleff A, Neubrand M, Sauerbruch T. Noninvasive endoscopic determination of intravariceal pressure in patients with portal hypertension: clinical experience with a new balloon technique. Endoscopy 1998; 30 (04) 326-332
- 24 Stiegmann GV, Goff JS, Michaletz-Onody PA. et al. Endoscopic sclerotherapy as compared with endoscopic ligation for bleeding esophageal varices. N Engl J Med 1992; 326 (23) 1527-1532
- 25 Mostafa EF, Mohammad AN. Incidence and predictors of rebleeding after band ligation of oesophageal varices. Arab J Gastroenterol 2014; 15 (3-4): 135-141
- 26 Augustin S, Altamirano J, González A. et al. Effectiveness of combined pharmacologic and ligation therapy in high-risk patients with acute esophageal variceal bleeding. Am J Gastroenterol 2011; 106 (10) 1787-1795
- 27 Laine L, Cook D. Endoscopic ligation compared with sclerotherapy for treatment of esophageal variceal bleeding. A meta-analysis. Ann Intern Med 1995; 123 (04) 280-287
- 28 Monescillo A, Martínez-Lagares F, Ruiz-del-Arbol L. et al. Influence of portal hypertension and its early decompression by TIPS placement on the outcome of variceal bleeding. Hepatology 2004; 40 (04) 793-801
- 29 Smith LA, Morris AJ, Stanley AJ. The use of hemospray in portal hypertensive bleeding; a case series. J Hepatol 2014; 60 (02) 457-460
- 30 Ibrahim M, El-Mikkawy A, Abdel Hamid M. et al. Early application of haemostatic powder added to standard management for oesophagogastric variceal bleeding: a randomised trial. Gut 2019; 68 (05) 844-853
- 31 Romero-Castro R, Ellrichmann M, Ortiz-Moyano C. et al. EUS-guided coil versus cyanoacrylate therapy for the treatment of gastric varices: a multicenter study (with videos). Gastrointest Endosc 2013; 78 (05) 711-721
- 32 Burke MP, O'Donnell C, Baber Y. Death from pulmonary embolism of cyanoacrylate glue following gastric varix endoscopic injection. Forensic Sci Med Pathol 2017; 13 (01) 82-85
- 33 Santos MM, Tolentino LH, Rodrigues RA. et al. Endoscopic treatment of esophageal varices in advanced liver disease patients: band ligation versus cyanoacrylate injection. Eur J Gastroenterol Hepatol 2011; 23 (01) 60-65
- 34 Ljubicić N, Bisćanin A, Nikolić M. et al. A randomized-controlled trial of endoscopic treatment of acute esophageal variceal hemorrhage: N-butyl-2-cyanoacrylate injection vs. variceal ligation. Hepatogastroenterology 2011; 58 (106) 438-443
- 35 Miyoshi H, Shikata J, Tokura Y. Endoscopic Clipping of Esophageal Varices. Dig Endosc 1992; 4 (02) 147-150
- 36 Yol S, Belviranli M, Toprak S, Kartal A. Endoscopic clipping versus band ligation in the management of bleeding esophageal varices. Surg Endosc 2003; 17 (01) 38-42
- 37 Escorsell À, Pavel O, Cárdenas A. et al; Variceal Bleeding Study Group. Esophageal balloon tamponade versus esophageal stent in controlling acute refractory variceal bleeding: A multicenter randomized, controlled trial. Hepatology 2016; 63 (06) 1957-1967
- 38 Choi JY, Jo YW, Lee SS. et al. Outcomes of patients treated with Sengstaken-Blakemore tube for uncontrolled variceal hemorrhage. Korean J Intern Med (Korean Assoc Intern Med) 2018; 33 (04) 696-704
- 39 Goenka MK, Goenka U, Tiwary IK, Rai V. Use of self-expanding metal stents for difficult variceal bleed. Indian J Gastroenterol 2017; 36 (06) 468-473
- 40 Shao XD, Qi XS, Guo XZ. Esophageal Stent for Refractory Variceal Bleeding: A Systemic Review and Meta-Analysis. BioMed Res Int 2016; 2016: 4054513-10
- 41 Pfisterer N, Riedl F, Pachofszky T. et al. Outcomes after placement of a SX-ELLA oesophageal stent for refractory variceal bleeding-A national multicentre study. Liver Int 2019; 39 (02) 290-298
- 42 Sinclair M, Vaughan R, Angus PW. et al. Risk factors for band-induced ulcer bleeding after prophylactic and therapeutic endoscopic variceal band ligation. Eur J Gastroenterol Hepatol 2015; 27 (08) 928-932
- 43 Cho E, Jun CH, Cho SB. et al. Endoscopic variceal ligation-induced ulcer bleeding: What are the risk factors and treatment strategies?. Medicine (Baltimore) 2017; 96 (24) e7157
- 44 Tierney A, Toriz BE, Mian S, Brown KE. Interventions and outcomes of treatment of postbanding ulcer hemorrhage after endoscopic band ligation: a single-center case series. Gastrointest Endosc 2013; 77 (01) 136-140.e1
- 45 Lopimpisuth C, Kerdsirichairat T, Khoshknab MP, Hamilton JP, Ngamruengphong S. Over-the-scope clip as salvage therapy in refractory bleeding from esophageal variceal band ligation-induced ulcer. Endoscopy 2020; 52 (01) E33-E34
- 46 Choudhary NS, Puri R, Saigal S, Saraf N, Sud R, Soin AS. Innovative Approach of Using Esophageal Stent for Refractory Post-Band Ligation Esophageal Ulcer Bleed Following Living Donor Liver Transplantation. J Clin Exp Hepatol 2016; 6 (02) 149-150
- 47 Sarin SK, Lahoti D, Saxena SP, Murthy NS, Makwana UK. Prevalence, classification and natural history of gastric varices: a long-term follow-up study in 568 portal hypertension patients. Hepatology 1992; 16 (06) 1343-1349
- 48 European Association for the Study of the Liver. Electronic address: easloffice@easloffice.eu, European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. [published correction appears in J Hepatol. 2018 Nov;69(5):1207] J Hepatol 2018; 69 (02) 406-460
- 49 Mishra SR, Sharma BC, Kumar A, Sarin SK. Primary prophylaxis of gastric variceal bleeding comparing cyanoacrylate injection and beta-blockers: a randomized controlled trial. J Hepatol 2011; 54 (06) 1161-1167
- 50 Bhat YM, Weilert F, Fredrick RT. et al. EUS-guided treatment of gastric fundal varices with combined injection of coils and cyanoacrylate glue: a large U.S. experience over 6 years (with video). Gastrointest Endosc 2016; 83 (06) 1164-1172
- 51 Lee YT, Chan FK, Ng EK. et al. EUS-guided injection of cyanoacrylate for bleeding gastric varices. Gastrointest Endosc 2000; 52 (02) 168-174
- 52 Bick BL, Al-Haddad M, Liangpunsakul S, Ghabril MS, DeWitt JM. EUS-guided fine needle injection is superior to direct endoscopic injection of 2-octyl cyanoacrylate for the treatment of gastric variceal bleeding. Surg Endosc 2019; 33 (06) 1837-1845
- 53 Mishra SR, Chander Sharma B, Kumar A, Sarin SK. Endoscopic cyanoacrylate injection versus beta-blocker for secondary prophylaxis of gastric variceal bleed: a randomised controlled trial. Gut 2010; 59 (06) 729-735
- 54 Hung HH, Chang CJ, Hou MC. et al. Efficacy of non-selective β-blockers as adjunct to endoscopic prophylactic treatment for gastric variceal bleeding: a randomized controlled trial. J Hepatol 2012; 56 (05) 1025-1032
- 55 Bang UC, Benfield T, Hyldstrup L, Jensen JE, Bendtsen F. Effect of propranolol on survival in patients with decompensated cirrhosis: a nationwide study based Danish patient registers. Liver Int 2016; 36 (09) 1304-1312
- 56 Ríos Castellanos E, Seron P, Gisbert JP, Bonfill Cosp X. Endoscopic injection of cyanoacrylate glue versus other endoscopic procedures for acute bleeding gastric varices in people with portal hypertension. Cochrane Database Syst Rev 2015; 5 (05) CD010180
- 57 Weilert F, Binmoeller KF. Endoscopic management of gastric variceal bleeding. Gastroenterol Clin North Am 2014; 43 (04) 807-818
- 58 Hou MC, Lin HC, Lee HS, Liao WC, Lee FY, Lee SD. A randomized trial of endoscopic cyanoacrylate injection for acute gastric variceal bleeding: 0.5 mL versus 1.0 mL. Gastrointest Endosc 2009; 70 (04) 668-675
- 59 Sarin SK, Jain AK, Jain M, Gupta R. A randomized controlled trial of cyanoacrylate versus alcohol injection in patients with isolated fundic varices. Am J Gastroenterol 2002; 97 (04) 1010-1015
- 60 Tantau M, Crisan D, Popa D, Vesa S, Tantau A. Band ligation vs. N-Butyl-2-cyanoacrylate injection in acute gastric variceal bleeding: a prospective follow-up study. Ann Hepatol 2013; 13 (01) 75-83
- 61 Tan PC, Hou MC, Lin HC. et al. A randomized trial of endoscopic treatment of acute gastric variceal hemorrhage: N-butyl-2-cyanoacrylate injection versus band ligation. [published correction appears in Hepatology. 2006 Jun;43(6):1410] Hepatology 2006; 43 (04) 690-697
- 62 Boustière C, Dumas O, Jouffre C. et al. Endoscopic ultrasonography classification of gastric varices in patients with cirrhosis. Comparison with endoscopic findings. J Hepatol 1993; 19 (02) 268-272
- 63 Romero-Castro R, Pellicer-Bautista FJ, Jimenez-Saenz M. et al. EUS-guided injection of cyanoacrylate in perforating feeding veins in gastric varices: results in 5 cases. Gastrointest Endosc 2007; 66 (02) 402-407
- 64 Iwase H, Suga S, Morise K, Kuroiwa A, Yamaguchi T, Horiuchi Y. Color Doppler endoscopic ultrasonography for the evaluation of gastric varices and endoscopic obliteration with cyanoacrylate glue. Gastrointest Endosc 1995; 41 (02) 150-154
- 65 Mohan BP, Chandan S, Khan SR. et al. Efficacy and safety of endoscopic ultrasound-guided therapy versus direct endoscopic glue injection therapy for gastric varices: systematic review and meta-analysis. Endoscopy 2020; 52 (04) 259-267
- 66 Bang JY, Al-Haddad MA, Chiorean MV. et al. Mo1485 Comparison of Direct Endoscopic Injection (DEI) and EUS-Guided Fine Needle Injection (EUS-FNI) of 2-Octyl-Cyanoacrylate for Treatment of Gastric Varices. Gastrointest Endosc 2015; 81 (05) AB437-AB437
- 67 Binmoeller KF, Weilert F, Shah JN, Kim J. EUS-guided transesophageal treatment of gastric fundal varices with combined coiling and cyanoacrylate glue injection (with videos). Gastrointest Endosc 2011; 74 (05) 1019-1025
- 68 Philips CA, Augustine P. Endoscopic Ultrasound-Guided Management of Bleeding Rectal Varices. ACG Case Rep J 2017; 4 (01) e101
- 69 Lebrec D. Ectopic varices in patients with portal hypertension. Arch Surg 1980; 115 (07) 890
- 70 Hosking SW, Smart HL, Johnson AG, Triger DR. Anorectal varices, haemorrhoids, and portal hypertension. Lancet 1989; 1 (8634): 349-352
- 71 Ganguly S, Sarin SK, Bhatia V, Lahoti D. The prevalence and spectrum of colonic lesions in patients with cirrhotic and noncirrhotic portal hypertension. Hepatology 1995; 21 (05) 1226-1231
- 72 Sato T, Yamazaki K, Toyota J, Karino Y, Ohmura T, Suga T. The value of the endoscopic therapies in the treatment of rectal varices: a retrospective comparison between injection sclerotherapy and band ligation. Hepatol Res 2006; 34 (04) 250-255
- 73 Sarin SK, Kumar CKN. Ectopic varices. Clin Liver Dis (Hoboken) 2012; 1 (05) 167-172
- 74 Labori KJ, Carlsen E. Treatment of bleeding peristomal varices. Eur J Surg 2002; 168 (11) 654-656
- 75 Cappell MS, Price JB. Characterization of the syndrome of small and large intestinal variceal bleeding. Dig Dis Sci 1987; 32 (04) 422-427
- 76 Wong F. Portal hypertensive gastropathy. Gastroenterol Hepatol (N Y) 2007; 3 (06) 428-473
- 77 Cubillas R, Rockey DC. Portal hypertensive gastropathy: a review. Liver Int 2010; 30 (08) 1094-1102